Review Article: Nutrition and the child with cancer: where do we stand and where do we need to go?

Nutrition and the child with cancer:

where do we stand and where do we need to go?

Nieuwoudt CH, BSc (Hons) (Dietetics), Postgrad Dipl Hospital Dietetics (US)
Little Company of Mary Medical Centre, Groenkloof, Pretoria
Correspondence to: Christina Nieuwoudt, e-mail: [email protected]

Abstract
As a result of ongoing research and better supportive care, the treatment of childhood malignancies has dramatically improved survival in
developed countries. The same cannot be said about the all important nutritional care of the child with cancer as much still needs to be
done to reach the ultimate goal, namely to provide evidence based nutritional intervention that will contribute to further improvements in
optimal outcomes. Furthermore, in developing countries, especially in Low Income Countries, malnutrition is only one aspect of socioeconomic
disadvantages that are associated negatively with many components of cancer control, from access to care, through to treatment compliance,
to long-term follow-up. In these settings economic evaluations of nutritional support in the form of cost-effectiveness and cost-utility analyses,
would be logical undertakings.
© SAJCN S Afr J Clin Nutr 2011;24(3): S23-S26

Introduction On the other side of the coin is the growing population of childhood
cancer survivors. Children with malignancies tolerate the acute
Over the last decades, the survival of children diagnosed with
side-effects of antineoplastic agents better than adults, but the
cancer in developed countries has increased substantially. Although
growing child is more susceptible to long-term diseases that have
individual prognosis varies according to type of cancer, available
implications for later life.1 In a recent report comparing the health
US data indicates that between 1975 and 1995 mortality from
status of 10 397 survivors of childhood cancer treated from 1970
childhood cancer declined with almost 40%.1 The five-year survival
to 1986 with 3 034 of their siblings, 62% of the survivors had at
rate of all combined childhood cancers is now approximately 80%.
least one chronic health condition, and 27% had a serious or life-
However, in developing countries the cure rate is much lower, due
threatening condition such as stroke, heart disease or kidney failure.
to multiple factors, including late diagnosis, under-diagnosis and
Survivors were 15 times more likely to develop a second malignancy
advanced treatments not always being available. A lack of accurate
than their siblings. Adverse health behaviours later in life, such as
epidemiological data makes the exact rate unknown. 2 HIV-related
smoking, drinking, poor diet and lack of exercise may increase the
immunosuppression further increases the incidence of certain types
risk of developing some of these complications.7
of cancers in children, e.g. Kaposi’s sarcoma and lymphomas. HIV-
infection and its co-morbidities such as tuberculosis (TB) make it
Malnutrition in childhood cancer
more difficult to treat diagnosed malignancies.3
The Free Medical Dictionary defines malnutrition as “the condition
Adequate nutrition during cancer plays an important role in clinical
that develops when the body does not get the right amount of
outcome measures, such as treatment response, quality of life and
the vitamins, minerals, and other nutrients it needs to maintain
cost of care. However, in a recent critical review of important aspects
healthy tissues and organ function”.8 Other definitions focus on
of nutrition in children with cancer it was found that the importance
protein-energy imbalances. More recently the American Society for
of nutrition in children and young adults with malignancies is still
Parenteral and Enteral Nutrition (ASPEN) has accepted Soeters and
underestimated.4 Between 5 and 50% of children and young adults
Schols’s9 umbrella definition of malnutrition: “A subacute or chronic
with cancer experience malnutrition at diagnosis, depending on the
state of nutrition, in which a combination of varying degrees of
diagnosis and the malnutrition criteria used. This is due to tumour-
overnutrition or undernutrition and inflammatory activity has led to a
and treatment-related factors.5 During treatment this figure can
change in body composition and diminished function.”10
increase with 40 -80%.6 Children are particularly vulnerable to
malnutrition due to increased substrate needs related to the disease, An adequate protein-energy balance is needed to sustain age-
treatment and limited reserves. At the same time, children have appropriate growth and maintenance. Although there is currently no
increased energy and nutrient requirements to attain appropriate consensus definition for malnutrition, weight and height parameters
growth and development. are most often used as indicators for malnutrition, but these are

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 Review Article: Nutrition and the child with cancer: where do we stand and where do we need to go?

not necessarily appropriate for children with cancer. Those with nutritional assessment must be followed, but obstacles will be faced
solid abdominal masses (neuroblastoma, hepatoblastoma, Wilms along the way.
tumour) may present with normal weights due to the mass of the
Anthropometrics: Weight is not a reliable indicator in an acute care
tumour. Furthermore, undetectable nutritional depletion of one or
setting due to dehydration, over-hydration, and disease mass and is
more micronutrients occurs in normal-, under- and/or over-weight
children. Current data regarding the prevalence of malnutrition in not an indicator of muscle loss. Arm anthropometry is recommended
children with cancer is influenced by different diagnostic techniques as it offers advantages over measures of height and weight and
used in nutrition assessment, type and stage of cancer during provides useful assessment of nutritional status, especially in
assessment, the child’s individual susceptibility toward malnutrition developing countries.13 The question however remains which
and treatment regimens as well as the non-specific definition of standard references to use in the childhood cancer setting.
malnutrition.4 Pathophysiological mechanisms that contribute to the
Biochemical data: Although data of blood concentration of nutrients
development of malignancy induced malnutrition and growth failure
and proteins can serve as a proxy of a patient’s current nutritional
include: i) complex interactions between energy and substrate
status, they need to be interpreted with current hydration status,
metabolism; ii) hormonal and inflammatory components; and
medications and drug-nutrient interactions in mind. For instance,
iii) alterations in metabolic compartments resulting in increased
mobilization and oxidation of substrates and loss of body proteins. serum albumin, a marker of protein status during starvation, is not
The type, stage and metastatic status of the disease and treatment useful during acute disease, because it is a negative phase protein
modalities are some of the main risk factors for malnutrition.4 that decreases during the acute phase response. Nevertheless, as a
marker of inflammation and acute illness, which is usually associated
Malnutrition in cancer patients is further aggravated by cancer
with reduced appetite and nutrient intake, hypoalbuminemia still
cachexia. In contrast to simple starvation where there is a relative
suggests a need for nutritional intervention. As such, albumin is
maintenance of lean body mass at the expense of body fat, cancer
often monitored together with C-reactive protein (CRP) to distinguish
cachexia is characterized by profound and progressive loss of both
lean body mass and body fat. Although malignancy induced cachexia between nutritional and inflammatory causes of low albumin and as
is not yet fully understood, it seems that the body’s compensatory a means to assess recovery from, for instance, an acute infection.1,14
mechanisms to conserve protein during simple starvation and As another example, lower antioxidant levels have been documented
decrease energy expenditure to allow prolonged survival are either and are associated with increased risk of toxicity (dose reductions),
lost or inhibited in certain cancers.4,11,12 infections, chemotherapy delays, days spent in the hospital and
decreased quality of life.6 A lower dietary intake of antioxidants had
Management of malnutrition in the paediatric cancer survivor
similar effects.15,16
The challenge in the management of children with malignancy
is to assess the nutritional needs of the paediatric oncology Clinical assessment: This is particularly important in children who
patient to provide the optimal nutrition intervention to prevent should be assessed for clinical signs and symptoms of depleted
or treat malnutrition and prevent its consequences. Short-term muscle and fat stores as well as micronutrient deficiencies.17
consequences include muscle and fat wasting with changed body Diet history: Apart from the usual information gathered during a
composition, decreased tolerance and response to chemotherapy,
diet history, the Children’s Oncology Group (COG) recommends
treatment delays, biochemical disturbances such as anaemia
that the history must also include information about the use of
and hypoalbuminaemia and higher susceptibility to infections.
supplements, herbs, or alternative therapies.17 It is estimated that
Long-term consequences include growth impairment, impaired
up to 85% of the pediatric oncology population use some form of
neurodevelopment, abnormal bone density, decreased quality of life
alternative medicine, including dietary supplements. Although some
and increased risk for secondary cancers.4
such supplements may be beneficial, others may interact with
In summary we therefore can say that we know where we stand, medications or cause adverse effects. Patients and their families
in that:
may not always feel comfortable to share their use of alternative,
• Many of newly diagnosed children with cancer will be mal-
often cultural medical and/or food practices. Therefore an open and
nourished or become malnourished during the course of
non-judgemental approach is needed to encourage families to share
treatment.
such practices so as to allow alternative modalities that are deemed
• Malnutrition (over- and under-nutrition) will negatively impact on
safe and appropriate to be integrated in the patient’s treatment.
the course of the disease and its treatment due to changes in
body composition. Well- designed research on the use of alternative dietary therapies
• Malnutrition, in many cases, impacts on the long-term human in the paediatric oncology patients is however lacking and is needed
potential and quality of life of the survivor of childhood cancer. to make sound recommendations.1

Nutritional assessment Nutrition support for children with cancer

“Adequate nutrition assessment is paramount for the decision A relative paucity of data on best practices contributes to the
making process of nutritional intervention”.6 The A, B, C, D of challenges in achieving the goals of nutrition support (Table I).

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 Review Article: Nutrition and the child with cancer: where do we stand and where do we need to go?

Table I: Goals of nutrition support in children with cancer interaction needs to be explored to answer questions about key
Sustain and promote normal growth 17 gene expression and genetic pathway alterations by specific
nutrients and/or combinations of nutrients.22 Supplementation with
Reverse malnutrition, if present17
glutamine is reported to relieve severe mucositis, but clear evidence
Prevent future malnutrition17
remains in need of confirmation.23-25 Equally, there is no consistent
Promote normal eating behaviours1
of confirmed evidence regarding the use of pre- and probiotics in
Improve quality of life1 this patient population. The American Academy of Paediatrics (AAP)
does not recommend their use in seriously or chronically ill children
until the safety of administration has been established.26 Pre- and
Criteria for intervention
probiotics may further alter anticancer drugs’ pharmacokinetics.22
Currently there are no universally agreed guidelines for nutrition The use of anti-oxidants is controversial as there are arguments for
intervention in the paediatric oncology population. In an international and against their inclusion in cancer treatment regimes. The findings
survey conducted by the COG, it was found that no standardized of such small scale studies with many uncontrolled variables are
nutrition protocols were being employed for nutrition intervention. inconsistent and in adequate to guide clinical practice.27
The effect of the varied and variable nutrition practices on the quality
Contraindications to EN are similar to those in other diseases. If no
of life, toxicity of cancer treatments and outcome in children with
EN is possible, PN is indicated without delay. A delay of three to seven
cancer remains largely unknown. As a result of this the COG Nutrition
days as suggested by some is thought to be detrimental to children
Committee developed an algorithm as a general guideline for
with preadmission protein energy malnutrition (PEM) and/or history
nutrition intervention in an effort to establish a base for appropriate
of poor dietary intake.1,4,17,28 When considering PN the impact of
clinical trials about nutrition and its impact on the child with cancer.18
specific lipid formulations should be considered. Recent knowledge
Nutrient requirements about the immunomodulating actions of ω-3 polyunsaturated fatty
There are no specific guidelines for nutrient requirements or the acids indicates that eicosapentanoic acid and docosahexanoic acid
changes that occur in the paediatric oncology population. Several may have different effects on the function and gene expression of
tools are available to estimate energy and nutrient needs of the immune cells.29,30 Furthermore, parenteral nutrition–associated liver
child with cancer, including age appropriate Dietary Reference disease (PNLD) remains a dreaded complication of PN in children.31
Intakes (DRIs) and the World Health Organization’s (WHO) equations New intravenous lipid emulsions containing fish oil have been
for basal metabolic rate. The difficulty in estimating nutrient shown to be beneficial and safe in the management of PNLD in
requirements is further augmented by the wide age range of paediatrics, but their impact on cancer treatments need to be further
paediatric patients and age specific requirements, ranging from explored.22,32,33 Whichever route of nutritional repletion is used, it
an infant weighing about 3 kg with minimal reserves to an obese needs to be borne in mind that the malnourished child with cancer
adolescent weighing 100 kg.1,4,17,18 The COG recommends that is at risk of refeeding syndrome, should aggressive nutritional
(i) cancer treatment may increase energy needs by approximately rehabilitation be implemented.17
20% and protein needs by as much as 50%; (ii) poor treatment In a recent Cochrane Review to determine the effects of any form
related dietary intake may necessitate a daily multivitamin and
of PN or EN support in children and young people with cancer
mineral supplement to meet daily recommended intake; and
undergoing chemotherapy, the authors concluded that there is
(iii) fluid status should be assessed and monitored to ensure proper
limited evidence from individual trials to suggest that PN is more
hydration.1
effective than EN in well-nourished children and young people with
Enteral or parenteral nutrition support?1 cancer undergoing chemotherapy. The evidence for other methods
of nutritional support remains unclear. No studies were identified
When oral intake remains inadequate to support growth or nutrition
comparing the nutritional content in the PN or EN groups of studies 34
repletion in a child with cancer, enteral nutrition (EN) should be
considered before the initiation of parenteral nutrition (PN). EN,
Where do we need to go?
in the presence of an intact gastrointestinal tract, preserves gut
integrity and prevents bacterial translocation, enhances immune Analysis of childhood cancer statistics in the US has shown that the rate
response and reduces the risk of infections.13,17 Studies in paediatric of decline in mortality from most cancers has decreased. This latter
oncology patients have demonstrated that EN is successful has been attributed to the consistent improvements in outcome from
in maintaining adequate nutritional status and in reversing sequential clinical trials by optimizing delivery of standard cytotoxic
malnutrition. Unfortunately, the use of EN is inconsistent.19 Some agents and other conventional therapeutic approaches (surgery,
of the treatment related side effects, such as mucositis discourage radiation therapy, and hematopoietic stem-cell transplantation). With
the use of EN. In addition, children may have neutropenia or the advent of targeted therapeutics, which is currently in its infancy,
thrombocytopenia that can increase their risk for bleeding when further improvements can be expected.35 At the same time it has
the tube is inserted; however, clinical trials have not supported been acknowledged that there is paucity of nutritional investigation
these theoretical risks.5,20,21 There is currently no evidence-based in children with cancer that needs to be addressed.18 Some of the
guidelines about the particular composition of EN in the paediatric areas to explore include the biological modification of disease by
oncology population. The three-way diet–chemotherapy–cancer nutrients, improved tolerance of chemotherapy and amelioration of

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 Review Article: Nutrition and the child with cancer: where do we stand and where do we need to go?

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Metab Care. 2009;12(5):487-94
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